--PRINTABLE Check Registration Form--

Student Registration Form

STUDENT REGISTRATION FORM

FULL NAME:

CELL PHONE:

ADDRESS:

BUSINESS PHONE:

Personal EMAIL:

WILL ATTEND CLASS on specified Dates:

DISCOUNTED TUITION LISTED BELOW

Property & Liability $280

Personal Lines $280

Adjuster $280

Life $140

Health $140

Medicare Supplement/LTC $145

TOTAL TUITION ENCLOSED: $

TUITION must be received by the Thursday PRIOR TO CLASS.

RETURNED CHECK and ADMIN FEE is $45.

Please clip this application and mail with tuition check payable to:

Insurance Educational Systems

P.O. Box 90684

RALEIGH, NC 27675

1-919-859-2104